Such is the care America provides its disposable, who survive on the nation’s scraps. From America’s inception, wealth has flowed upward, whether from slave to master or from worker to boss. The disposable person stands in a chasm cut by centuries of movement. With great effort she can scale the walls: the victory of emancipation, and the gains won by the labor movement, have forced America to embody more of its self-professed democratic ideals. Yet those walls are still unacceptably high, and the disposable have far to reach before they know security. To get there, they must battle a political economy that sees them not as a people but as a site of extraction. When they are healthy, the system will siphon wealth from their labor. In sickness, their bodies are all that is left. Here at the end, the system sucks up its last profits until she is spent.
The Affordable Care Act reduced the ranks of the uninsured and kept people alive, but it’s still possible to slip through the cracks in the law. As a market-based attempt at reform, the ACA was never that radical; it did not remove the profit motive from health care. Yet it, too, had enemies. The ACA provoked ludicrous hostility when first introduced: On her popular Facebook page, former Alaska governor and vice presidential candidate Sarah Palin accused President Obama of creating “death panels” to exterminate seniors and the sick. Palin’s precise scenario never came to be, but the ex-governor hadn’t quite invented the dynamic she allegedly feared. Death panels do exist. They predated the Affordable Care Act and survived its implementation. All countries ration health care to some extent, but the U.S. “is unique because of the complex, sometimes hidden, and frequently unintended ways it rations care,” wrote Beatrix Hoffman in the introduction to her 2012 book, Health Care for Some: Rights and Rationing in the United States Since 1930.
The U.S. recognizes no universal right to health care, Hoffman observed; instead, it is only guaranteed for some groups, like veterans who are eligible to enroll in the VA system. Citing the scholar David Mechanic, Hoffman distinguished between explicit rationing, where official rules govern the distribution or denial of care, and implicit rationing, which is broader, and encompasses “different access to care” depending on a person’s insurance status and ability to pay. Though Americans fear explicit rationing, the consequences of implicit rationing rarely make headlines, Hoffman wrote. That’s beginning to change, due to public outcry and the rising popularity of proposals like Medicare for All.
Though a mythology of personal liberty can obscure the extent to which the U.S. rations care, news outlets and some politicians are pulling back the veil. Reality is becoming difficult to ignore, although power lies, still, with the entities like private health insurance companies. Every day, insurance companies ration or deny care, and they don’t yet fear the consequences of their actions. In 2023, the news website ProPublica obtained a damning recording: in it, a nurse employed by UnitedHealthcare told her colleague that a doctor under contract had decided that a patient’s ulcerative colitis treatment was no longer necessary. The colleague laughed. “I knew that was coming,” he said.
